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The Most Prevalent Pediatric Healthcare Problem In Colorado


The Most Prevalent Pediatric Healthcare Problem In Colorado Affects 1/3 of Colorado s Children 400,000 children Affects 40% of all newborns in Colorado – PowerPoint PPT presentation

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Title: The Most Prevalent Pediatric Healthcare Problem In Colorado

The Most Prevalent Pediatric Healthcare
ProblemIn Colorado
  • Affects 1/3 of Colorados Children
  • 400,000 children
  • Affects 40 of all newborns in Colorado

Compared to the general pediatric population,
this condition causes
  • More serious illness (1.77 times)
  • More emergency room visits (1.85 times)
  • More hospitalizations (1.73 times)
  • Higher complication rates (1.78 times)
  • Higher death rates (1.67 times)

Compared to the general pediatric population,
this condition causes
  • Later diagnosis of serious illness
  • Poorer understanding of their chronic illnesses
  • Poorer access to specialized care for
    complicated illness
  • Lower immunization rates
  • Less preventive care in general
  • Lower compliance with medical treatment
  • Lower school attendance

Colorado is 50th Among the States in Per Capita
Spending to Manage This Problem
  • What is it?

How would you define poverty?
How would you define poverty?
  • Lack of sufficient income to live adequately by
    community standards

Federal Poverty Guidelines
  • FPG used to determine eligibility for many
    federally supported programs
  • Federal Poverty Threshold used by census bureau
    for statistical purposes
  • Originally, the amount of income needed to feed
    the members of a household without having to
    spend more than 1/3 of their income on food.
  • Now, more complicated food, shelter, clothing
  • Considered to be an underestimate of true

2006 HHS Poverty Guidelines
What is Poverty?
  • For a two parent / two child family
  • the threshold is 20,000 annually
  • which is what the average Wal-Mart employee
  • makes
  • but that employee doesnt get health insurance as
    a benefit
  • To be able to afford health insurance, you need
    more than 40,000/year (which is close to the
    mean income in the US)
  • Health insurance premiums can be 8,000 to
    15,000 a year

Poverty and Children
  • Official poverty rate in the US for children -
  • But for a family to afford food, housing,
    clothing, utilities, child care and
    transportation, and especially to afford health
    care, the family must be well over 200 of the
  • Children in families at or less than 200 FPL
  • Newborns born into families lt 200 FPL 40
  • Children eligible for Medicaid or CHP - 34

Poverty in Colorado
of all Coloradans of poor families
White, non-Latino 75 35
Latino 17 47
African-American 4 10
Other 4 8
But, is poverty simply a matter of low income?
  • New definition
  • Lack of sufficient income and resources to live
    adequately by community standards

Basic Resources(often needed in low income
  • Money
  • Food
  • Housing..Home
  • Clothing
  • Transportation
  • Child Care
  • Safetyfreedom from fear or violence
  • Manageable level of Stress
  • Education
  • Information
  • Health Care

Basic Resources(often needed to get out of
  • A trusted source of advice and support
  • Love, caring
  • Role modeling,
  • Mentoring, guidance
  • Help
  • Encouragement, positive reinforcement
  • Experience, success

Community Services
  • WIC
  • CHP

  • 3 year old known asthmatic has had 2 ED visits
    for exacerbations in the past 2 months and three
    office visits for wheezing in past 2 months.
    Providers added Flovent, Singulair and
    Salmeterol. Gave 2 steroid bursts.

Case (continued)
  • Mother changed PCPs. New PCP took social
    history. Over past the past 2 months
  • Electricity shut off in apartment for 1 month
  • Then evicted
  • Went to live with relatives (3 smokers)
  • Car died, took buses (winter months)
  • Eating 2 meals a day

Screening Questions
  • Face-to-face gt questionnaire
  • Conveys interest
  • Can observe reaction
  • At least once a year (at health maintenance
  • Develop routine
  • Who, how, when, where
  • Only ask if you are prepared to respond

How to start
  • As a health care provider, I am not only
    interested in your childs physical health. I am
    also interested in the whole child and the whole
    family. I ask all families several questions to
    see if there are ways our practice can be of
  • How are things at home these days?
  • Are there any difficult stresses at home?
  • Are there things you wish were different?
  • What does your family need that would make
    things better?
  • What do you need in terms of help or resources?

Welfare reform legislation of 1996 Personal
Responsibility and Work Opportunity
Reconciliation Act
  • Before Aid to Families with Dependent Children
    (AFDC) established in 1935 as part of the social
    security act to aid single mothers.
  • Now Temporary Assistance for Needy Families
  • Federal money given as block grants to states,
    with incentives for the states to move people
    from welfare to work.

Temporary Assistance for Needy Families (TANF)
  • Used to be known as welfare
  • Monthly cash assistance program for poor families
    with children under age 18.
  • Family of three (mother and two children)
    qualifies if monthly income is below 784 and
    assets are worth less than 1000.
  • Maximum benefit (family of 3) - 357 benefit
  • States decide what categories of needy families
    to help, counties administer

Application for Assistance
  • 31 pages
  • over 200 questions
  • Up to 9 documents required
  • Driver's license or birth certificate
  • Pay stubs
  • Letter showing money received from social
    security, SSI, VA, child support, etc.
  • Most recent rental agreement or letter from
  • Most recent mortgage statement
  • Utility bills, such as electricity, gas, and
    heating oil
  • Cancelled checks for day care for child(ren)
  • Medical bills that you pay (if you are 60 or
    older, or disabled) and
  • Court order or cancelled checks for child support
  • Application also applies for
  • Food Stamps
  • Medicare/Medicaid
  • Financial assistance

  • The four purposes of TANF are
  • assisting needy families so that children can be
    cared for in their own homes
  • reducing the dependency of needy parents by
    promoting job preparation, work and marriage
  • preventing out-of-wedlock pregnancies
  • encouraging the formation and maintenance of
    two-parent families.

  • Teen Parent Live-at-Home and Stay-in-School
  • Work Requirements if child over 1 year old.
  • Education, training or working.
  • Working within 24 months
  • Individual Responsibility Contract.
  • Counties have discretion.
  • Four-Year Time Limit average length of time on
    welfare 18 months.
  • Allowable activities
  • orientation and assessment
  • mental health evaluation and treatment
  • substance abuse evaluation
  • domestic violence prevention therapy
  • parenting skills training
  • job search/job readiness activities beyond the
    six-week countable criteria
  • basic skills training
  • GED classes
  • and applying for needed services

  • More information for you
  • http//
  • For families to apply - call their county
    department of social services

Working Family Assistance (WFA)
  • Denver County as an example - many other counties
    have this
  • Child under 18
  • Income lt 225 FPG
  • Help with cash, child care, housing,
  • Can ask for help 3 times (twice in one year)
  • Maximum benefit 1,000 per request
  • Denver Department of Human Services

Food Security
  • 11 of American households were food insecure
  • not enough food for an active, healthy life for
    all household members at sometime during the
  • 3.5 prevalence of food insecurity with hunger
    during the year.
  • Many options

Food Stamps
  • EBT card (electronic benefit transfer)- a plastic
    card similar to a bank debit card to transfer
    funds from a food stamp benefits account to a
    retailer's account.
  • Take card to a participating grocery store (at
    least one in every county)
  • Application TANF
  • Apply at county Dept. Human Services or Social

Food Stamps
  • Complicated system for determining eligibility
  • Application form same as TANF
  • Interview
  • Documents must bring
  • Driver's license or birth certificate
  • Pay stubs
  • Letter showing money received from social
    security, SSI, VA, child support, etc.
  • Most recent rental agreement or letter from your
  • Most recent mortgage statement
  • Utility bills, such as electricity, gas, and
    heating oil
  • Cancelled checks for day care for your child
  • Medical bills that you pay (if you are 60 or
    older, or disabled) and
  • Court order or cancelled checks for child support
  • Local food stamp office 1-800-221-5689 or
    303-866-2536 http//

Food Stamps
Updated October 2005, effective through September
People in Household Gross Monthly Income Limits Net Monthly Income Limits
1 1,037 798
2 1,390 1,070
3 1,744 1,341
4 2,097 1,613
5 2,450 1,885
6 2,803 2,156
7 3,156 2,428
8 3,509 2,700
Each additionalperson... 354 272
Food Stamps
  • Employment Requirements
  • Immigrant Eligibility Requirements

Food Stamps
Allotment Chart (October 1, 2005 through Sept.
30, 2006)
People in Household Maximum Monthly Allotment
1 152
2 278
3 399
4 506
5 601
6 722
7 798
8 912
Each additional person... 114
Food Stamps
  • Households CAN use food stamp benefits to buy
  • Foods for the household to eat, such as
  • breads and cereals
  • fruits and vegetables
  • meats, fish and poultry and
  • dairy products.
  • Seeds and plants which produce food for the
    household to eat.
  • Households CANNOT use food stamp benefits to buy
  • Beer, wine, liquor, cigarettes or tobacco
  • Any nonfood items, such as
  • pet foods
  • soaps, paper products and
  • household supplies.
  • Vitamins and medicines.
  • Food that will be eaten in the store.
  • Hot foods

WIC Program (Women, Infants and Children)
  • Population Served low-income, nutritionally at
  • Pregnant women (through pregnancy and up to 6
    weeks after birth or after pregnancy ends).
  • Breastfeeding women (up to infants 1st
  • Non-breastfeeding postpartum women (up to 6
    months after the birth of an infant or after
    pregnancy ends) 
  • Infants (up to 1st birthday).
  • Children up to their 5th birthday.

WIC Program
  • Eligibility
  • Income
  • At or below 185 percent of the U.S. Poverty
    Income Guidelines (currently 34,873 for a family
    of four).
  • Automatically eligible if qualify for Food
    Stamps, Medicaid, for Temporary Assistance for
    Needy Families.
  • At "Nutrition risk"
  • means that an individual has medical-based or
    dietary-based conditions.  Examples of
    medical-based conditions include anemia,
    underweight, slow weight gain, lack of
    resources, or history of poor pregnancy
    outcome.  A dietary-based condition includes, for
    example, a poor diet. Usually determined at a
    WIC clinic.
  • They rarely say no

  • Benefits
  • Supplemental nutritious foods 
  • Nutrition education and counseling at WIC
  • Screening (growth parameters and Hematocrit) and
    referrals to other health, welfare and social
  • WIC services are provided
  • county health departments
  • hospitals
  • mobile clinics (vans)
  • community centers
  • schools
  • public housing sites
  • migrant health centers and camps
  • Indian Health Service facilities

  • Foods
  • The foods provided are high in one or more of the
    following nutrients protein, calcium, iron, and
    vitamins A and C.
  • Foods frequently lacking in the diets of the
    programs target population.
  • WIC foods include
  • Infants iron-fortified infant formula (Similac
    w/ iron, Isomil, Similac Lactose Free) and
    infant cereal
  • Children iron-fortified adult cereal, vitamin
    C-rich fruit or vegetable juice, eggs, milk,
    cheese, peanut butter, dried beans/peas, tuna
    fish and carrots.
  • Special therapeutic infant formulas (Nutramigen,
    Pregestimil, Alimentum) and medical foods are
    provided when prescribed by a physician for a
    specified medical condition.

WIC Income Eligibility Guidelines(Effective from
July 1, 2005 to June 30, 2006)
  Annual Monthly
1 17,705 1,476
2 23,736 1,978
3 29,767 2,481
4 35,798 2,984
5 41,829 3,486
6 47,860 3,989
7 53,891 4,491
8 59,922 4,994
Each Add'l Member Add 6,031 503
  • Nutrition Services  Colorado Department of
    Health  FCHSD-NS-A4  4300 Cherry Creek Drive,
    South  Denver, CO 80246-1530
  • telephone (303) 692-2400  toll-free in-state
    1-800-688-7777 fax (303) 756-9926  website

Food Other Services
  • The Commodity Supplemental Program (CSFP) -
    lt185FPL - residing in the following counties
    Denver, Weld, Pueblo, Mesa, Rio Grande, Conejos
    and Costilla, if they are not eligible for (or
    already participating in) the WIC Program.     
  • National School Lunch Program subsidy for
    schools to provide free lunch to low income
  • The Child and Adult Care Food Program (CACF)   -
    in child care centers
  • Charitable Institutions (CI) surplus foods made
    available to charities to give out.     

Housing Programs
  • Low-rent housing government provides funds
    directly to apartment owners, who lower the rents
    they charge low-income tenants.
  • To apply Ask apartment manager
  • Public Housing is apartments for low-income
    people, operated by local housing agencies.
  •  To apply Contact county social services or
    public housing agency
  • Housing Choice Vouchers (formerly called "Section
    8") the eligible individual finds own place to
    rent, using a voucher.
  • To apply contact county social services or
    local housing agency.
  • Local rental programs - Your state and local
    governments may use HUD funds to create local
    rental programs.
  • Contact state and county governments to find
  • Rural Rental Assistance Programs Programs and
    Services in Federal Rental Housing
  • Each program may have different income limits

Section 8Rental housing assistance payment
  • Low income (income limits tables change each
  • Paying more than 50 of gross income for housing
  • Living in substandard housing
  • Involuntarily displaced (natural disaster)
  • Priorities
  • Families of 2 or more
  • Disabled
  • Seniors
  • Perform eight hours of community service each
    month (some exemptions TANF)
  • Application county dept. of social services

Food, Clothing and Utilities Assistance
  • Food, clothing, home and utilities assistance is
    available to those who qualify. The resource
    locations in all counties.
  • Just Call 211 Information and Referral
  • or call the front desk and they will direct you
    to someone that can help.
  • Or call 303-433-8383

Energy Assistance
  • LEAP Low income Energy Assistance Program
  • Application through county social services
  • Colorado resident
  • Financial help, never pays full cost
  • Help with weatherizing house or furnace service

  • Household size Max Gross Monthly Income
  • 1 1,475
  • 2 1,978
  • 3 2,481
  • 4 2,983
  • 5 3,486
  • 8 4,993 (nearly 60,000)

  • Non-Emergency Medical Transportation (NEMT)
  • for Colorado Medicaid recipients
  • LogistiCare Facility Line - 1-800-390-3182 for
    the following counties
  • Adams, Arapaho, Boulder, Broomfield, Douglas,
    Jefferson and Larimer
  • NECTA Services
  • Phone 1-866-734-6666 for the following
  • Sedgwick, Phillips, Yuma, Washington
  • Red Willow Services
  • Phone 719-589-5734 for the following counties
  • Alamosa, Costilla, Conejos, Rio Grande, Mineral
    and Saguache
  • These contractors are NOT responsible for
    EMERGENT medical transportation.
  • All other counties are the responsibility of the
    local county of human or social services.

Child Care
  • When apply for TANF, there is complicated system
    for determining eligibility for additional money
    for child care
  • Colorado state law must provide child care
    assistance to families earning less than 130
    percent of the FPL level (income lt1,504/ mo)
  • Most counties set cutoff between 144 and 185
    FPL (2,139/mo)
  • There may be a waiting list in some counties for

Legal Problems
  • Is anyone in your household having legal
  • Do you think you or anyone in your household
    might benefit from legal resource assistance?

Legal Assistance
  • Legal Assistance
  • Help for low-income Coloradans seeking civil
    legal information, including self-help legal
    information, where to find legal assistance,
    court information, and for other help available
    in your community.
  • Colorado Legal Services1905 Sherman, Ste.
    400Denver, CO 80203303.837.1313www.ColoradoLega
  • Legal advocates helping low-income individuals in
    civil legal matters. Membership is offered as a
    free benefit to civil legal aid attorneys, pro
    bono attorneys, law students and faculty and
    other legal aid advocates. www.COAdvocatesForum.o
  • For criminal matters, go to the Public Defender's
    website. http//
  • Email

Emotional Support
  • Who in your life would be able to handle a
    situation like this well?
  • Who can and will help you with this situation?
  • Who really cares about you and is good at
  • Do you feel like you would benefit from having
    someone to call when you feel like you need to
    talk to someone?

  • Parent Support-line Provide a listening ear for
    times when parenting is tough, and they have good
    referral information. Callers experience great
    comfort being able to discuss problems that
    appear overwhelming.
  • Trained volunteers are available 10 a.m. 10
    p.m. At other times, one can leave a message and
    someone will call them back with-in 24 hours.
  • PHONE 303/695-7996
  • Consejos para familias- 1-800-527-3264
  • For parents of children with special health care
    needs Family Voices 800-881-8272

Domestic Violence
  • As a pediatrician, I am interested in the safety
    of all family members.
  • Ask about fire detectors, firearms, electrical
    outlet covers
  • Do you feel your children are safe at home?
    Do you feel safe?
  • Have you been hurt or threatened at home? Have
    your children been hurt at home or in your

Domestic Violence
  • Document mothers comments in chart
  • Document discussion and recommendations
  • Asses whether injury to, or risk to, child
  • Acknowledge, empathize, support, express concern
    for safety
  • Provide community resources (phone numbers)
  • Help develop a plan for safety (see web sites)
  • Refer child for counseling?

Domestic Violence State Law
  • Mandatory
  • Must report injury caused by a weapon
  • Must report intentionally inflicted injury
  • Judgment call
  • Imminent risk to child age of child, degree of
    violence, ability of parent to protect
  • When in doubt ask social worker or hotline

Domestic Violence Resources
  • Crisis Hotlines
  • National - 1-800-799-SAFE
  • Colorado phone numbers http//
  • Safe House and Shelters - http//
  • Handout on personal safety plan

Mental Health
  • Access Behavioral Health Care (Denver County)
  • Behavioral Healthcare Inc.
  • - Adams County 303/853-3500
  • - Arapahoe County 303/617-2300
  • - Aurora, Douglas Counties 303/779-9676
  • Foothills Behavioral Health
  • - Boulder, Broomfield Counties 303/443-8500
  • - Gilpin, Jefferson Counties
  • CHP Carrier
  • - Colorado Access 720/751-9030
  • - CHP Managed Care Network 800/334-6557
  • - Denver Health 303/436-5622
  • - Kaiser 303/338-3800
  • Samaritan Institute
  • - 303/639-5240

Substance Abuse
  • Is anyone in your household having trouble with
  • Is anyone in your household having trouble with
  • Does anyone in your household smoke?
  • As you know smoking is bad for your childs
  • Can I offer information on ways to stop

  • Alcohol and Drug Abuse
  • All of the resources for Colorado are listed on

  • Quitline is a counseling service that connects
    people who want to quit smoking with trained
    counselors who can guide and support them through
    the quitting process. This service is available
    to anyone in the state in both English and
  • QUITLINE 1/800-639-QUIT
  • E-MAIL

Developmental Evaluations
  • The Individual with Disabilities Education Act
    (IDEA) targets all children with disabilities
    aged birth to 21 who reside in the state.
  • Early Childhood Connections Birth to 3
  • Child Find 3-21years

Early Childhood Connections
  • Birth to 3 years
  • Screening /developmental evaluation, based on
    parent or provider concern
  • No cost to family
  • Individualized Family Service Plan
  • Developmental level
  • Need for treatment or services
  • Service coordinator
  • Help in finding services and funding
  • Prognosis
  • ECC 1-888-777-4041
  • Each county has a service provider
  • For example in Denver Option funds from state
    to provide special services 303-247-8423

Early Childhood Connections
  • Eligible
  • Developmental delays
  • Language
  • Hearing
  • Motor
  • Adaptive (cognitive)
  • Social/emotional
  • Conditions normally associated with delays
  • Chromosomal
  • Congenital syndromes (like Spina Bifida)
  • Metabolic (like PKU)
  • Perinatal infections (Like HIV or CMV)
  • Cerebral palsy
  • Ex-preemies (less than 1200 grams)
  • Attachment disorder

Early Childhood Connections
  • Who pays for the treatment services?
  • Health plan
  • Community resources
  • Family
  • The IFSP helps the family identify resources

Child Find
  • 3-21 years old
  • Through school district or 303-866-6943
  • Screening /developmental evaluation, based on
    parent or provider concern
  • No cost to family
  • IEP or 504 can be developed from these screenings

Health Care
Case 1
  • A single mother of 2 children has been in your
    practice for a couple of years. Mother had
    health insurance at her last job, but was laid
  • Now works for Wal-Mart in a job that does not
    include health insurance. Your practice does not
    provide care for uninsured patients.
  • How can her insurance be paid for?

Health Care
  • Medicaid 0 to 133 of FPG
  • CHP - 133 to 200 of FPG
  • CICP low income families missed by Medicaid and
  • Only it is a lot more complicated.

Colorado Medicaid
  • Federally- and state- funded, state run
  • 50 federal funds and 50 state funds
  • Bottom 10 of state in funding

Medicaid General Eligibility Criteria
  • Colorado Residency
  • US Citizenship
  • Low income and
  • Pregnant Women(up to 133 FPG family of 4
    makinglt23,225/y) until 60 days after child is
    born or pregnancy is terminated
  • Children and TeenagersChildren 0-5 y.o. up to
    133 FPG
  • Children 6-18 y.o. up to 100 FPG
  • Or if child is sick enough to need nursing home
    care, but could stay home with good quality care
    at home
  • Subsidized adoption or foster care.
  • Waiver children- qualify due to extraordinary
    service needs
  • Eligible for SSI
  • Aged (65 years old or older) OR
  • Blind OR
  • Disabled
  • Terminally ill and want to receive hospice
  • Live in a nursing home
  • Disabled and Mentally Ill adults
  • Some Other Situations

Application for Assistance
  • 31 pages
  • over 200 questions
  • 9 documents required
  • Driver's license or birth certificate
  • Pay stubs
  • Letter showing money received from social
    security, SSI, VA, child support, etc.
  • Most recent rental agreement or letter from your
  • Most recent mortgage statement
  • Utility bills, such as electricity, gas, and
    heating oil
  • Cancelled checks for day care for your child
  • Medical bills that you pay (if you are 60 or
    older, or disabled) and
  • Court order or cancelled checks for child support
  • Application also applies for
  • Food Stamps
  • Medicare/Medicaid
  • Financial assistance

Medicaid and CHP Application
  • Revised application now down to 8 pages
  • Still about 100 questions
  • up to 6 documents required

What is EPSDT?
What is EPSDT?
  • Early Periodic Screening, Diagnosis and Treatment

EPSDTEarly and Periodic Screening, Diagnostic,
and Treatment
  • Medicaid's comprehensive and preventive child
    health benefits
  • 0-20 years
  • Any medically necessary
  • health care service

  • Medicaid children must receive from their PCP
  • the following services
  • Unclothed, head-to-toe physical exam
  • Mental/behavioral health screening
  • Health history
  • Developmental assessment
  • Immunizations - Committee on Immunization
    Practices (ACIP) for pediatric vaccines)
  • Nutritional assessment
  • Vision and hearing screenings
  • Health education and anticipatory guidance
  • Maternity and family planning
  • STD assessment
  • Diagnosis, treatment and care coordination of
    acute and chronic conditions
  • Lead screen assessment- at 12 months and 24
    months of age.

  • It is what you routinely do
  • It is the regular care recommended by the AAP-
  • Bright Futures
  • Periodicity Schedule
  • The Medical Home
  • Plus lead screening

EPSDTIn addition..
  • Referrals to specialists and EPSDT Outreach
    coordination services
  • Vision Services - At a minimum, includes referral
    for diagnosis and treatment for defects in
    vision, including eyeglasses.
  • Dental Services referral for routine screening
    and care beginning at age 1
  • Hearing Services -- At a minimum, referrals for
    services include diagnosis and treatment for
    defects in hearing, including hearing aids and
    the Colorado Home Intervention program

  • Health care benefits
  • Outreach helping parents use the health
  • Understand the health benefits
  • Deal with the barriers
  • Information about, help finding, a PCP
  • Help getting to appointments
  • Handling eligibility lapses
  • Follow-up on missed appointments
  • Client has missed enough appointment to be in
    danger of being discharged from the practice
  • Medical urgency child has not returned for
    needed medical treatment
  • Phone number by county of residence
  • Adams County 303-255-6266 or 6253
  • Aurora (Adams or Arapaho) 303-341-9370
  • Arapahoe, Douglas, Elbert 303-761-1340
  •  Denver (720) 956-2093
  • Jefferson County(303) 271-4379 or 4375

Medicaid MCOs (HMOs)(Colorado Access and Denver
  • Cover
  • Preventive care
  • Acute care
  • Hospitalization
  • Specialty care CO Access no longer require
    prior authorization for most specialties

Wrap Arounds
  • Services not covered by the MCO, but covered by
    State Medicaid directly
  • Dental care
  • Mental Health
  • Medical Transportation
  • Orthodontic care (only for severe or handicapping
  • Require Prior Authorization Form (PAR) and letter
    of medical necessity
  • Private duty nursing
  • Hospice
  • Skilled nursing facility
  • Certain special treatments, therapies
  • Special appliances like a hearing aid, a
    hospital bed at home

Case 2
  • Your patient is on Medicaid
  • He has hypotonia due to a rare muscular
    dystrophy, plus has severe cardiomyopathy with
  • Mother has advanced MS
  • She requests an electric hospital bed for home

This Child Needs
  • Require Prior Authorization Form (PAR)
  • Letter of medical necessity.for the Mom

Medical Necessity
  • Accepted standard of medical practice
  • Clinically appropriate type, frequency and
  • Not for convenience of child, parent, provider

For questions or additional teaching
  • Gina Robinson
  • 303-866-6167

Medicaid Problems
  • 12 month eligibility as long as still qualify
  • If a family member applies for another program,
    could loose eligibility temporarily
  • In some counties it could take 2-4 months from
    date application is received to be fully enrolled
  • CBMS
  • Churn
  • Reimbursement

Chart 22 Distribution of Persons Served Through
Medicaid and Payments by Basis of Eligibility,
Fiscal Year 2000
Payments for the elderly, blind and disabled
account for 73 percent of total payments and only
27 percent of persons served.
Blind Disabled
Note (1) "Payments" describe direct Medicaid
provider payments and Medicaid program
expenditures for premium payments to third
parties for managed care, as well as cost sharing
on behalf of persons served who are dually
enrolled in Medicaid and Medicare, but exclude
DSH payments and Medicare premiums. (2) This
chart excludes 3.7 million persons served with
unknown basis of eligibility and 6.5 billion
expenditures on behalf of persons served with
unknown basis of eligibility in FY 2000. If
included in the total above, unknown Medicaid
persons served would have comprised about 9
percent of total persons served and about 4
percent of total expenditures. Source CMS, MSIS.
Recipient of all recipients of budget Change in per pt spending last 5 years
Children 58 17 -20
Parents 14 11 16
Pregnant Women 2 2 46
Disabled 12 29 39
Elderly 10 37 20
Immigrants in ED 2 3 68
Private Pediatric Practice
  • Cost per patient visit
  • Average - 70
  • Range - 60-80
  • Medicaid reimbursement per patient visit
  • Average - 45
  • Medicaid HMO reimbursement per visit
  • Average - 60
  • Average range of reimbursement from commercial
    insurance companies
  • 50 - 90

Case 3
  • A family calls your practice to bring the
    children in for illness care
  • Father has been out of work, but has just gotten
    an entry level job a Wal-Mart. Mother has MS and
    stays home with the 2 children.
  • How will their care be paid for?

CHP(Child Health Plan Plus)
  • Children age 18 and under
  • In families that earn or own too much to be
    eligible for Medicaid
  • At or below 200 of the FPG
  • Colorado Resident
  • US Citizens or permanent US residents who have
    had an Alien Registration Number for at least 5
    years (Exceptions refugees, deportees, asylees,
    Cuban-Haitians, and Ameri-Asians)
  • 800.359.1991

CHP Also Provides Prenatal Care
  • Age 19 and over
  • Not eligible for Medicaid
  • Living in a financially qualified Colorado
  • US citizens or permanent US residents who have
    had an Alien Registration number for at least 5
    years (there are certain exceptions to this,
    including refugees and asylees)
  • Not covered by any other health insurance or
    currently working for the State of Colorado

  • Annual fee 35 a year
  • Co-pay
  • None for preventive care
  • 1-5 for illness care
  • 3-15 for urgent or emergent care

Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table Eligibility Lookup Table
Family Size Family Size Family Size Family Size Family Size Family Size Annual Payment Annual Payment Co-payment for each office visit
1 Person 2 People 3 People 4 People 5 People 6 People One Child 2 or More Children Co-payment for each office visit
Up through 9,570 Up through 12,830 Up through 16,090 Up through 19,350 Up through 22,610 Up through 25,870 No Fee No Fee No Copay
9,571 to 14,355 12,831 to 19,245 16,091 to 24,135 19,351 to 29,025 22,611 to 33,915 25,871 to 38,805 No Fee No Fee 2 per Visit
14,356 to 19,140 19,246 to 25,660 24,136 to 32,180 29,026 to 38,700 33,916 to 45,220 38,806 to 51,740 25 per year 35 per year 5 per Visit
CHP / Benefits
  • Preventative Care
  • Prenatal Care
  • Transplant Services
  • Surgery
  • Medical Office Visits
  • Vision and Audiology
  • Labs and X-Rays
  • Mental Health
  • Prescription Drugs
  • Therapies
  • Emergency Care and Transportation
  • Durable Medical Equipment

Case 4
  • The father in a family in your practice owns his
    own business and makes just enough to not qualify
    for Medicaid or CHP, but cannot afford health
  • His 6 week old needs to be admitted for
    bronchiolitis and hypoxia

Colorado Indigent Care Program (CICP)
  • Provides partial reimbursement to providers for
    offering medical care to eligible underinsured
    and uninsured residents.
  • Administered by Colorado Department of Health
    Care Policy and Financing (HCPF)
  • Not a health insurance program
  • Services restricted to participating hospitals
    and clinics throughout the state.
  • Medical services vary by participating health
    care provider. Responsible physician determines
    what services will be covered.
  • Services include (not limited to) emergency care,
    inpatient care, outpatient care, and prescription

CICP Eligibility
  • Some local hospitals and clinics enroll families
    into the CICP.
  • Technicians complete the applications.
  • Eligibility
  • Colorado residency (or migrant laborer) and a
    U.S. citizen
  • Income and asset requirements at or below 185 of
    the Federal Poverty Level (FPL), and cannot be
    eligible for Medicaid.
  • There are no age limitations for CICP
  • Can have Medicare or other commercial health
    insurance policy, but these policies must be
    exhausted before CICP reimburses the health care
  • Assigned a "rate" based on total income and
  • Ratings cover services that were received up to
    90 days prior to your application.
  • Rating determines how much co-payments will be
    for the year.

CICP Co-payment Cap
  • Never have to pay more than 10 of family income
    in a 12-month calendar period.
  • Family is responsible for keeping track of the
    co-payments and letting the provider know once
    the family has reached the 10 co-payment cap

CICP Documentation
  • Up to 10 documents required
  • State of Colorado drivers license or state
    identification card
  • Proof of immigration status
  • Copies of last months' paycheck stubs
  • Social Security Disability Insurance (SSDI) or
    Supplemental Security Income (SSI) award letter
  • Payments from pension plans
  • Payments from Aid to the Needy and Disabled (AND)
    or Old Age Pension (OAP)
  • A copy of your Medicare or health insurance card
  • Vehicle value for all of your vehicle(s)
  • Other income sources
  • Non-CICP medical/pharmacy/dental expenses

Colorado Indigent Care Program Client Co-payment Table Colorado Indigent Care Program Client Co-payment Table Colorado Indigent Care Program Client Co-payment Table Colorado Indigent Care Program Client Co-payment Table Colorado Indigent Care Program Client Co-payment Table Colorado Indigent Care Program Client Co-payment Table
N 40 15 0 5 3
A 62 64 27 10 5
B 81 103 44 10 5
C 100 154 66 10 5
D 117 220 94 10 10
E 133 297 127 15 15
F 159 389 167 20 20
G 185 535 230 25 25
Community Pediatrics
  • Steve Poole, MD
  • 303-861-6004

Case 5
  • You are on the pediatric indigent care list for
    your community hospital
  • You see a newborn whose mother is on Medicaid.
  • Your practice has a policy of not accepting
    Medicaid patients.
  • The baby is 48 hours old and the mother is being
    discharged from the hospital
  • You tell he mother to have her child seen in the
    next 3-4 days for follow-up.
  • The mother calls your office later in the week
    saying she cannot find a practice that will
    accept her baby.

January, 2005
  • Accepted Medicaid or CHP children
  • 22 of Colorado pediatric practices
  • 15 of Colorado family practices were a

  • In Colorado 140,000 Medicaid/CHP eligible
    children in Colorado do not have an assigned,
    consistent source of primary health care.
  • In metro Denver 75,000 Medicaid/CHP eligible
    children in Metro Denver do not have an assigned
    consistent source of primary health care.
  • Colorado has very good public clinics, but there
    are too few to meet this need.

Why dont private practices accept Medicaid and
CHP children?
  1. Poor reimbursement (85)
  2. Poor access to mental health services for child
    and mother (76)
  3. Hassles claims, enrollment, enrollment
    verification, maintenance of enrollment,
    authorizations and referrals. (75)
  4. Need access to financial counseling (73)
  5. Practices need an experienced social worker (73)
  6. Need case management (59)
  7. Low vaccination rates, inadequate records. (55)
  8. After-hours telephone care (50)
  9. Lack of transportation (50)

The Colorado Childrens Healthcare Access Program
  • Mission
  • To develop, implement and evaluate sustainable
    and replicable models of health care to encourage
    and enable private practices to provide high
    quality, cost effective health care for children
    of low income families throughout Colorado.

Colorado Childrens Healthcare Access Program
  • Funded by
  • Health ONE Alliance
  • Rose Community Foundation
  • Colorado Trust
  • Caring For Colorado
  • Piton Foundation
  • Community Child Health Foundation
  • Pioneer Fund
  • Amer Chair at Childrens Hospital

Colorado Childrens Healthcare Access Program
  • In kind support
  • Colorado Department of Health Care Policy and
    Financing (Colorado State Medicaid)
  • Colorado
  • The Childrens Hospital
  • University of Colorado School of Medicine, Deans
  • Colorado State Department of Health
  • Colorado Health Institute
  • Colorado Health Outcomes Program
  • Colorado Chapter of the American Academy of
  • Behavioral Health Incorporated and Foothills
    Behavioral Health
  • Denver Samaritan Counseling Center is
  • Department of Child Psychiatry, University of
    Colorado School of Medicine.
  • Colorado Community Health Network
  • Division of Community Pediatrics of the
    University of Colorado School of Medicine
  • Division of Epidemiology of the University of
    Colorado School of Medicine

  • Surveys in November of 2004 and January 2005,
  • Eighty-five percent of Colorado pediatricians
  • if the barrier are adequately addressed
  • willing to devote up to 10 of their practice
  • If all private practice pediatricians
  • and 1/2 of the family physicians in Colorado
  • devoted 10 of their practices to Medicaid, CHP
    then all children in Colorado could have PCP

CCHAP data
  • If Medicaid child has PCP
  • ED utilization reduced 2 ½ times
  • Hospitalization reduced by 40
  • Cost of care reduced 2 times
  • Immunization rates doubles
  • Quality of care improves